Peptic ulcer disease: Difference between revisions
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==Evaluation==
==Evaluation==
[[File:PMC3835032 1752-1947-7-257-2.png|thumb|Perforated duodenal ulcer presenting with a subphrenic abscess: (A) a huge air-fluid collection (asterisk) can be seen in the right subphrenic space with mild stranding of the surrounding fat (arrow). There are also reactive pericardial and pleural effusions, the latter with associated atelectasia of the right lung base (arrowheads). In (B) the air-fluid collection (asterisk) appears to extend to the perihepatic space. Extraluminal air bubbles can also be detected in the fissure of Teres’ ligament (arrow).]]
===Work-Up===
===Work-Up===
*CBC (rule out anemia)
*CBC (rule out anemia)

Revision as of 18:35, 28 November 2019

Background

A benign gastric ulcer (from the antrum of a gastrectomy specimen).
  • Recurrent ulcerations in the stomach and proximal duodenum
    • Defect in the gastric or duodenal wall that extends through the muscularis mucosa into the deeper layers of the wall[1]
  • Majority of cases related to H. pylori or NSAID use
    • H. pylori found in 30-40% of U.S. population
    • NSAIDs inhibit prostaglandin synthesis (decreases mucus and bicarb production)

Clinical Features

  • Burning epigastric pain
    • May awaken patient at night (gastric contents empty)
  • Abrupt onset of severe pain may indicate perforation
  • Abrupt onset of back pain may indicate penetration into the pancreas
  • The following symptoms are NOT associated with PUD:
    • Postprandial pain, food intolerance, nausea, retrosternal pain, belching


Complications

  • Hemorrhage
  • Perforation
    • Most commonly occurs in anterior wall of duodenum.
    • Abrupt onset of severe epigastric pain
    • Patients may not have history of ulcer-like symptoms
    • Upright or left lateral decub XR for intraabdominal air
    • Consult surgery
  • Obstruction
    • Occurs due to:
      • Scarring of gastric outlet
      • Edema due to active ulcer

Differential Diagnosis

Epigastric Pain

Upper gastrointestinal bleeding

Mimics of GI Bleeding

Evaluation

Perforated duodenal ulcer presenting with a subphrenic abscess: (A) a huge air-fluid collection (asterisk) can be seen in the right subphrenic space with mild stranding of the surrounding fat (arrow). There are also reactive pericardial and pleural effusions, the latter with associated atelectasia of the right lung base (arrowheads). In (B) the air-fluid collection (asterisk) appears to extend to the perihepatic space. Extraluminal air bubbles can also be detected in the fissure of Teres’ ligament (arrow).

Work-Up

  • CBC (rule out anemia)
  • LFTs
  • Lipase
  • Consider acute abdominal series if concern for perforation (>50 years old; concerning abdominal exam)
  • Consider RUQ US
  • Consider ECG
  • Consider troponin

Evaluation

Acute duodenal acute duodenal mucosal ulcer on endoscopy
  • Diagnosis not typically definitively made in ED (requires endoscopy or H. pylori test)
  • Depending on clinical certainty can consider initial empiric treatment

Management

Disposition

  • Normally outpatient management, unless complication (see below)

Red Flags

Any of the following suggest need for endoscopy referral:

See Also

References

  1. ↑ Vakil N. Peptic ulcer disease: Management. UpToDate. https://www.uptodate.com/contents/peptic-ulcer-disease-management?search=ulcer treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1. Published September 16, 2019. Accessed November 5, 2019.
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